Social determinants of health and risk for Long COVID in the U.S. RECOVER-Adult cohort
Feldman, CH; Santacroce, L; Bassett, IV; et al., Annals of Internal Medicine
Published
July 2025
Journal
Annals of Internal Medicine
Abstract
Background: Social determinants of health (SDoH) contribute to disparities in SARS-CoV-2 infection, but their associations with long COVID are unknown.
Objective: To determine associations between SDoH at the time of SARS-CoV-2 infection and risk for long COVID.
Design: Prospective observational cohort study.
Setting: 33 states plus Washington, DC, and Puerto Rico.
Participants: Adults (aged ≥18 years) enrolled in RECOVER-Adult (Researching COVID to Enhance Recovery) between October 2021 and November 2023 who were within 30 days of SARS-CoV-2 infection; completed baseline SDoH, comorbidity, and pregnancy questionnaires; and were followed prospectively.
Measurements: Social risk factors from SDoH baseline questionnaires, ZIP code poverty and household crowding measures, and a weighted score of 11 or higher on the Long COVID Research Index 6 months after infection.
Results: Among 3787 participants, 418 (11%) developed long COVID. After adjustment for demographic characteristics, pregnancy, disability, comorbidities, SARS-CoV-2 severity, and vaccinations, financial hardship (adjusted marginal risk ratio [ARR], 2.36 [95% CI, 1.97 to 2.91]), food insecurity (ARR, 2.36 [CI, 1.83 to 2.98]), less than a college education (ARR, 1.60 [CI, 1.30 to 1.97]), experiences of medical discrimination (ARR, 2.37 [CI, 1.94 to 2.83]), skipped medical care due to cost (ARR, 2.87 [CI, 2.22 to 3.70]), and lack of social support (ARR, 1.79 [CI, 1.50 to 2.17]) were associated with increased risk for long COVID. Living in ZIP codes with the highest (vs. lowest) household crowding was also associated with greater risk (ARR, 1.36 [CI, 1.05 to 1.71]).
Limitation: Selection bias may influence observed associations and generalizability.
Conclusion: Participants with social risk factors at the time of SARS-CoV-2 infection had greater risk for subsequent long COVID than those without. Future studies should determine whether social risk factor interventions mitigate long-term effects of SARS-CoV-2 infection.
Primary funding source: National Institutes of Health.
Authors
Candace H Feldman, Leah Santacroce, Ingrid V Bassett, Tanayott Thaweethai, Radica Alicic, Rachel Atchley-Challenner, Alicia Chung, Mark P Goldberg, Carol R Horowitz, Karen B Jacobson, J Daniel Kelly, Stacey Knight, Karen Lutrick, Praveen Mudumbi, Sairam Parthasarathy, Heather Prendergast, Yuri Quintana, Nasser Sharareh, Judd Shellito, Zaki A Sherif, Brittany D Taylor, Emily Taylor, Joel Tsevat, Zanthia Wiley, Natasha J Williams, Lynn Yee, Lisa Aponte-Soto, Jhony Baissary, Jasmine Berry, Alexander W Charney, Maged M Costantine, Alexandria M Duven, Nathaniel Erdmann, Kacey C Ernst, Elen M Feuerriegel, Valerie J Flaherman, Minjoung Go, Kellie Hawkins, Vanessa Jacoby, Janice John, Sara Kelly, Elijah Kindred, Adeyinka Laiyemo, Emily B Levitan, Bruce D Levy, Jennifer K Logue, Jai G Marathe, Jeffrey N Martin, Grace A McComsey, Torri D Metz, Tony Minor, Aoyjai P Montgomery, Janet M Mullington, Igho Ofotokun, Megumi J Okumura, Michael J Peluso, Kristen Pogreba-Brown, Hengameh Raissy, Johana M Rosas, Upinder Singh, Timothy VanWagoner, Cheryl R Clark, Elizabeth W Karlson
Keywords
Not available
Short Summary
This RECOVER study looked at how social determinants of health (SDoH) affect the risk of developing Long COVID after getting COVID-19. SDoH are the living and working conditions that affect a person’s health, such as how safe a neighborhood is, access to education, and how easy it is to get healthcare. Between October 2021 and November 2023, RECOVER researchers studied adults from 33 states, Washington, DC, and Puerto Rico who recently had COVID-19. These adults filled out surveys about their social situations, health conditions, and pregnancy status. The researchers followed them for 6 months to see who developed symptoms of Long COVID. They looked at SDoH including money problems, not having enough food, level of education, problems getting health care, having friends or family for support, and where someone lives. Out of 3,787 participants, 418 people (about 11%) developed Long COVID. Researchers found that people with money problems, not enough food, less education, trouble getting healthcare, and little social support had a higher risk of experiencing Long COVID. The researchers suggest that future studies explore whether addressing SDoH-related needs can help lower the chance of developing long-term effects of COVID-19.